- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.21 / $1,201.21 / $1,201.21
| Professional | | $1,201.21 | $1,201.21 | $1,201.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,465.00 / $2,958.00 / $4,762.00
| Professional | | $2,465.00 | $2,958.00 | $4,762.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,222.77 / $2,004.22 / $2,839.32
| Professional | | $1,222.77 | $2,004.22 | $2,839.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,376.10 / $3,252.60 / $3,971.87
| Professional | | $1,376.10 | $3,252.60 | $3,971.87 |